Cardiac Tamponade

Audience This simulation is designed to educate emergency medicine residents and medical students on the recognition and management of cardiac tamponade, as well as encourage providers to become familiar with their states’ disclosure laws for sentinel events. Introduction Cardiac tamponade is an emergent condition in which the accumulation of pericardial fluid and the consequent increase in hydrostatic pressure becomes severe enough to compromise the normal diastolic and systolic function of the heart, resulting in hemodynamic instability.1 The causes of cardiac tamponade are numerous because it is a potential complication of any of a number of pericardial disease processes, including infectious, inflammatory, traumatic, and malignant etiologies.1,2 Clinical presentations may vary and symptoms can be non-specific, which can lead to delayed or missed diagnoses and poor patient outcomes.3 In addition to this, the incidence of this condition is rising due to the increasing frequency of cardiac procedures performed (ie, pacemaker placement).4 Therefore, it is important for medical providers to have a high index of suspicion for the diagnosis based on patient presentation and to quickly provide necessary treatment to stabilize the patient. Educational Objectives By the end of this simulation session, the learner will be able to: (1) describe a diagnostic differential for dizziness (2) describe the pathophysiology of cardiac tamponade (3) describe the acute management of cardiac tamponade, including fluid bolus and pericardiocentesis (4) describe the electrocardiogram (ECG) findings of pericardial effusion (5) describe the ultrasound findings of cardiac tamponade (6) describe the indications for emergent bedside pericardiocentesis versus medical stabilization and delayed pericardiocentesis for cardiac tamponade (7) describe the procedural steps for pericardiocentesis, and (8) describe your state’s laws regarding disclosure for sentinel events. Educational Methods This session is conducted using high-fidelity simulation, followed by a debriefing session on evaluation and treatment of cardiac tamponade. However, it may also be run as an oral board case. Educational Methods Our residents were provided an electronic survey at the completion of the debriefing session so they may rate different aspects of the simulation, as well as provide qualitative feedback on the scenario. This survey is specific to the local institution’s simulation center. Results Feedback was largely positive because many learners mentioned during debriefing that they are not comfortable with pericardiocentesis and have limited opportunities to practice the procedure. None of our residents were familiar with our state’s or institution’s disclosure laws for sentinel events. The local institution’s simulation center feedback form is based on the Center of Medical Simulation’s Debriefing Assessment for Simulation in Healthcare (DASH) Student Version Short Form with the inclusion of required qualitative feedback if an element was scored less than a 6 or 7.5 This session received a majority of 6 (consistently effective/very good) and 7 scores (extremely effective/outstanding). Discussion This is a potential method for educating future medical providers on the diagnosis and management of cardiac tamponade in an emergency department setting. Learners initially had a wide range of differentials for the chief complaint of dizziness. We used an ECG with low voltage but without electrical alternans. When asked to provide an ECG interpretation, low voltage was intermittently explicitly interpreted by learners. We were concerned that if we showed an ECG with electrical alternans, learners may quickly arrive at the diagnosis without focusing on the subtleties of a physical exam, including looking for jugular venous distention (JVD) or pulsus paradoxus. We did not have the patient decompensate if their international normalized ratio (INR) was not immediately reversed, given likely delay for in vivo coagulation to occur in the face of life-threatening tamponade, but this provided a robust discussion during debriefing if reversal should be emergently initiated. Many residents voiced that they were uncomfortable performing a pericardiocentesis because they only had a few opportunities to do so on human cadavers, and they appreciated the opportunity to review this. Unexpectedly, when the patient asked the learners if he should sue the cardiologist, the majority of groups told the patient that the cardiologist was not liable because tamponade is a known complication of cardiac ablation and likely reviewed this while obtaining informed consent. None of the learners were familiar with Ohio’s disclosure laws for sentinel events. This identified a gap in knowledge that may be addressed in future learning sessions. Our main take-away is to continue providing low-frequency, high-acuity cases that provide the opportunity to review infrequent pathologies and procedures, as well as including patient safety and administrative learning points. Topics Medical simulation, cardiac tamponade, pericardial effusion, cardiac emergencies, obstructive shock, sentinel events, iatrogenic injury, medical disclosure.

Introduction: Cardiac tamponade is an emergent condition in which the accumulation of pericardial fluid and the consequent increase in hydrostatic pressure becomes severe enough to compromise the normal diastolic and systolic function of the heart, resulting in hemodynamic instability. 1 The causes of cardiac tamponade are numerous because it is a potential complication of any of a number of pericardial disease processes, including infectious, inflammatory, traumatic, and malignant etiologies. 1,2Clinical presentations may vary and symptoms can be non-specific, which can lead to delayed or missed diagnoses and poor patient outcomes. 3In addition to this, the incidence of this condition is rising due to the increasing frequency of cardiac procedures performed (ie, pacemaker placement). 4Therefore, it is important for medical providers to have a high index of suspicion for the diagnosis based on patient presentation and to quickly provide necessary treatment to stabilize the patient.
Educational Objectives: By the end of this simulation session, the learner will be able to: (1) describe a diagnostic differential for dizziness (2) describe the pathophysiology of cardiac tamponade (3) describe the acute management of cardiac tamponade, including fluid bolus and pericardiocentesis (4) describe the electrocardiogram (ECG) findings of pericardial effusion (5) describe the ultrasound findings of cardiac tamponade (6) describe the indications for emergent bedside pericardiocentesis versus medical stabilization and delayed pericardiocentesis for cardiac tamponade (7) describe the procedural steps for pericardiocentesis, and (8) describe your state's laws regarding disclosure for sentinel events.
Educational Methods: This session is conducted using high-fidelity simulation, followed by a debriefing session on evaluation and treatment of cardiac tamponade.However, it may also be run as an oral board case.Educational Methods: Our residents were provided an electronic survey at the completion of the debriefing session so they may rate different aspects of the simulation, as well as provide qualitative feedback on the scenario.This survey is specific to the local institution's simulation center.
Results: Feedback was largely positive because many learners mentioned during debriefing that they are not comfortable with pericardiocentesis and have limited opportunities to practice the procedure.None of our residents were familiar with our state's or institution's disclosure laws for sentinel events.
The local institution's simulation center feedback form is based on the Center of Medical Simulation's Debriefing Assessment for Simulation in Healthcare (DASH) Student Version Short Form with the inclusion of required qualitative feedback if an element was scored less than a 6 or 7. 5 This session received a majority of 6 (consistently effective/very good) and 7 scores (extremely effective/outstanding).
Discussion: This is a potential method for educating future medical providers on the diagnosis and management of cardiac tamponade in an emergency department setting.Learners initially had a wide range of differentials for the chief complaint of dizziness.We used an ECG with low voltage but without electrical alternans.When asked to provide an ECG interpretation, low voltage was intermittently explicitly interpreted by learners.We were concerned that if we showed an ECG with electrical alternans, learners may quickly arrive at the diagnosis without focusing on the subtleties of a physical exam, including looking for jugular venous distention (JVD) or pulsus paradoxus.
We did not have the patient decompensate if their international normalized ratio (INR) was not immediately reversed, given likely delay for in vivo coagulation to occur in the face of life-threatening tamponade, but this provided a robust discussion during debriefing if reversal should be emergently initiated.
Many residents voiced that they were uncomfortable performing a pericardiocentesis because they only had a few opportunities to do so on human cadavers, and they appreciated the opportunity to review this.
Unexpectedly, when the patient asked the learners if he should sue the cardiologist, the majority of groups told the patient that the cardiologist was not liable because tamponade is a known complication of cardiac ablation and likely reviewed this while obtaining informed consent.None of the learners were familiar with Ohio's disclosure laws for sentinel events.This identified a gap in knowledge that may be addressed in future learning sessions.Our main take-away is to continue providing low-frequency, high-acuity cases that provide the opportunity to review infrequent pathologies and procedures, as well as including patient safety and administrative learning points.

Linked objectives and methods:
Cardiac tamponade is an uncommon emergency department (ED) diagnosis with many of the symptoms associated with it being consistent with more common diagnoses.The most important tool for diagnosis of this life-threatening condition is maintaining a high clinical suspicion.This simulation scenario allows learners to review the patient presentation and highlights the importance of obtaining pertinent past medical and surgical histories.Learners will have the opportunity to perform an initial assessment and explore the vast differential diagnosis of a critically ill patient with nonspecific complaints (objective 1), administer an intravenous (IV) fluid bolus to counteract tamponade physiology (objective 2), and perform early resuscitative measures (objective 3).Learners will need to acquire and interpret appropriate studies (ECG and ultrasound) to diagnose cardiac tamponade (objective 4 and 5).They will then need to apply appropriate clinical judgment in a resourcelimited setting and perform a simulated pericardiocentesis (objectives 6 and 7).Afterwards, there will be discussion about the etiology and pathophysiology of cardiac tamponade, appropriate diagnosis and management of this condition, and review of indications and steps for pericardiocentesis (objectives 1-7).After reviewing the medical aspects of the case, there should also be a separate discussion regarding medical error disclosure and their medico-legal implications, as well as state-and institution-dependent laws and policies (objective 8).

Recommended pre-reading for instructor:
We recommend that instructors become familiar with the materials listed below under "References/suggestions for further reading."

Results and tips for successful implementation:
This simulation was written to be performed as a high-fidelity simulation scenario but may also be used as a mock oral board case.We conducted this scenario three times for a total of eight emergency medicine residents divided into groups of two or three learners during November 2019.Interns and medical students may be provided with an ECG that shows electrical alternans, but we found using an ECG with low voltage without alternans created a slightly more difficult case.Covering the pericardiocentesis task trainer with a sheet prevented immature diagnostic closure for our learners with increased situational awareness, as well as keeping the bedside ultrasound off to the side of the room.While still ultrasound images are included here, we suggest using ultrasound videos for increased fidelity.
The local institution's simulation center feedback form is based on the Center of Medical Simulation's Debriefing Assessment for Simulation in Healthcare (DASH) Student Version Short Form with the inclusion of required qualitative feedback if an element was scored less than a 6 or 7. 5 This session received all 6 (consistently effective/very good) and 7 scores (extremely effective/outstanding) with the exception of one 5 score (mostly effective/good) for the category "The instructor identified what I did well or poorly -and why."The form also includes an area for general feedback about the case at the end.

List of Resources:
Abstract Ultrasound pericardial effusion #9 Ultrasound plethoric Inferior Vena Cava (IVC) Background and brief information: Patient is a 50-year-old male who presents with chief complaint of dizziness.

Initial presentation:
Patient is a 50-year-old male who appears his stated age.He does not appear to be in cardiopulmonary distress and he is answering questions appropriately.
How the scene unfolds: Patient will report symptoms of dizziness.When asked to clarify further, patient will describe "feeling like I'm going to pass out" and deny any vertiginous sensation.Patient will further describe acute onset of lightheadedness earlier in the day that occurred at rest and worsens with standing.If asked about associated symptoms, patient will report shortness of breath that is worsened by exertion, but deny any other complaints, including chest pain, palpitations, or syncope.Vitals are notable for tachycardia with mild hypotension.
If patient is given resuscitative fluid boluses, his hypotension will improve transiently, but the hypotension will ultimately worsen.If learners attempt to contact cardiology, the cardiologist will be busy in the catheterization lab, prompting learners to perform bedside pericardiocentesis.
The patient will ask learners what is going on and if this is the cardiologist's fault.The patient will then ask the learners if he should sue the cardiologist.
If patient is not promptly (less than 5min) given resuscitative fluids, patient will begin to decompensate with worsening hypotension and increasing tachycardia until patient is given IV fluids.If IV fluids continue to be withheld and a pericardiocentesis is not performed in a timely fashion, patient will go into PEA arrest.Return of spontaneous circulation (ROSC) is then at the discretion of the facilitator, but ROSC may occur after pericardiocentesis is successfully performed.

History:
• History of present illness: Patient reports sudden onset of dizziness which began 6 hours ago at rest.When asked, he describes it as feeling "like I'm going to pass out" and worsens with standing.He also reports associated shortness of breath, worsening with exertion.
If asked, he has had a recent ablation procedure 2 days ago for symptomatic atrial fibrillation refractory to rate control.He has continued his warfarin and has been compliant with this.Denies any other medication changes.
•  Participants should recognize cardiac tamponade on ultrasound and make decision to perform pericardiocentesis.
If participants request consultant (cardiology, cardiothoracic surgery, etc.), consultant will be unavailable.
Upon successful completion of pericardiocentesis, participants should be prompted for disposition (if not already determined previously) and END CASE.this condition typically present with symptoms consistent with shock, such as lightheadedness, as well as symptoms of venous pooling of fluid secondary to the obstruction, including shortness of breath, chest discomfort, leg edema, etc.In addition, patients may present with vital sign abnormalities such as tachycardia and hypotension.As a result of this non-specific presentation, the initial diagnostic workup for these patients will need to be broad to include a multitude of common etiologies of shock (ie, sepsis, myocardial infarction, hemorrhage, pulmonary embolism, etc.).] • ECG findings: A number of ECG findings have been associated with cardiac tamponade, including low voltage QRS complexes, PR segment depression, and electrical alternans.Although research in this area is somewhat limited by the rarity of this condition, general consensus is that these findings are poorly sensitive for the condition but are relatively specific and can be suggestive of the diagnosis if observed. 12-16• Echocardiography findings: While the definitive diagnosis of cardiac tamponade was previously diagnosed using pulsus paradoxus, the increasing availability and sophistication of point-of-care ultrasound has greatly improved the emergency physician's ability to diagnose this condition in an efficient and accurate manner at bedside.The findings typically seen on ultrasound correlating with cardiac tamponade include systolic right atrial (RA) collapse (earliest finding), diastolic right ventricle (RV) collapse, plethoric inferior vena cava (IVC) with minimal respiratory variation, as well as mitral valve inflow variation.While a pericardial effusion, typically with circumferential involvement, is a pre-requisite to a diagnosis of tamponade, the size of the effusion itself cannot be correlated to the presence of acute tamponade physiology. 10• Pericardiocentesis Technique: Pericardiocentesis has traditionally been taught as a blind subxiphoid approach.More recently, support for more novel ultrasound-guided approaches (ie, parasternal) is on the rise, but the evidence for these approaches in an emergency department setting is limited.In this case, a traditional subxiphoid approach was reviewed during debriefing, although learners were also encouraged to use ultrasound guidance for a subxiphoid approach: [17][18][19] 1. Palpate the xyphoid process.Move 2 fingerbreadths inferior to this and then 2 fingerbreadths laterally to the left (just below the costal margin).2. Insert needle at 30 degrees, directed towards the left shoulder.Aspirate as the needle is advanced.Ultrasound may be used for ultrasound guidance, if available.

Additional Debriefing Points:
• When asking patients to elaborate on their dizziness, the authors prefer to ask the patient to "Describe your dizziness without using the word 'dizzy.'"This may help distinguish vertiginous symptoms from presyncope.Further questioning may reveal if there were any associated symptoms, such as chest discomfort, dyspnea, vision change, or palpitations.While vertigo may lead down a cerebellar pathology diagnostic pathway, presyncope isn't without underlying harmful etiologies.It is hypothesized it has a similar underlying cause of global cerebral hypoperfusion as syncope, 21 and presyncope was associated with a significant number of adverse outcomes.
eturn: Calibri Size 10 Chu A, et al.Cardiac Tamponade.JETem 2020.5(4):S84-107.https://doi.org/10.21980/J81D1D 100 Cardiac Tamponade • Pathophysiology: Cardiac tamponade is a rare life-threatening condition evolving from a fluid collection within the pericardial sac.As fluid accumulates within this closed space, the pressure exerted by the fluid increases.When this pressure becomes greater than the filling pressures within the chambers of the heart (~5 mmHg for right ventricle, ~10 mmHg for left ventricle for an average adult individual), filling becomes compromised, resulting in obstructive shock and hemodynamic collapse. 1,2,4• Etiology: The causes of cardiac tamponade are numerous; any condition that may lead to development of pericardial effusions (infection, malignancy, recent MI, autoimmune disorders, etc.) can also theoretically result in cardiac tamponade.However, certain etiologies of pericardial effusions which lead to a more rapid rate of fluid accumulation (ie, hemorrhagic) are more likely to induce tamponade physiology. 1,2,8• Pulsus paradoxus: Inflate a blood pressure cuff on the patient's arm.As you deflate the cuff, have the patient exhale.Record the first Korotkoff sound.Repeat the measurement, but have the patient inhale while auscultating.If the difference between the two sounds is greater than 10mmHg, it may be classified as pulsus paradoxus.• Diagnostic testing: Because cardiac tamponade is a form of obstructive shock, patients with

3 .
When blood return is obtained, remove up to 30 cc of fluid.If ultrasound is available, you may inject fluid back in to confirm location of the needle tip.If the needle is appropriately positioned, you should visualize turbulence in the pericardial fluid and not within the ventricles.4. Continue to remove pericardial fluid until patient's vital signs improve (usually requires approximately 30cc, but more may be needed).
This case was great!Forced you to think through a lot of different pathology and do a rare procedure," as well as, "these cases are always quite humbling for me and I appreciate the feedback after the cases a lot.I feel much more in tune with tamponade awareness now after this case," and "I appreciated learning what we did that changed the trajectory of our patient, and what would have yielded a different outcome.Patient is a 50-year-old male who presents with chief complaint of dizziness in the setting of a recent ablation procedure for atrial fibrillation.He is anticoagulated on warfarin.Initial vitals will be notable for tachycardia and hypotension which will continue to decompensate to pulseless electrical arrest (PEA) if providers do not quickly perform bedside pericardiocentesis.